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HomeMy Public PortalAbout4901 AGNES AVE_Sewer_3/20/1987_master remodel W ORKERS'COMPESATION DECLARATION firm .that I 'have a'cel�ificate of consent to self Pa certificatf of Norkers' Compensation Insurance, or 76A642D certified copyt�?er of (Sec. 3800, Lab C., CE 808(REV.8/81) APPLICATION FOR PERMIT Policy No._�q-' Company Ste" FKNA ©s ❑ Certified copy is hereby fu'rnished. SEWER - SEWAGE DISPOSAL ertified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY epartme t. Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CE TIFICATE OF,EXEMPTION FROM ORKERS' BUILDING GN�3 STATION DEPTH COMPENSATION INSURA E ADDRESS Jul N, (This section need not be completed if the work involved by the O( C MANHOLE REFERENCE OWER UPPER permit is for one hundred dollars ($100)or less.) LOCALITY NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. aLeAg. ZLf R!� Y. CURB P.I. M.I.TO P.L. permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. Q P.C. No. I p OWNER r /h CO.IMP.NO. JOB NO. MAIL Date Applicant MA ADDRESS ,j 'y"!J� TRUNK PERMIT NO. ROAD PERMIT NO. AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of Ciry TEL.No. Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION ( No.of BLDGS. PERMIT No. SIZE OF LOT 35 NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR 0pei'mi (.� 6. &df.{geas CONNECTION CHARGE FEE License Number Lic.Class , a Lt,'.' REIMBURSEMENT FEE °�� ADDRESS � � � CantraClOr Date 1 DISTRICT NO. GROUP MAP PROCESSED BY CITY p(/Jil� y TEL.NO. C� .S STATE LIC ��(� /t/ BK PG ❑ I am exempt nder Sec, of the L.A.Co. LICENSE No. 14 Is anss e NO. DESCRIPTION OF W RK FEE -V Plumbing Code and/or Sec. of the HOUSE SEWER CONNECTING TO FI EL ® ® VALIDA ON PUBLIC SEWER �- B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR TINA PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO B PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL WORK O HOUSE EWER BLDG.OR O OWNER-BUILDER DECLARATION OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE 267 0.8 A Law for the following reason(Secton 7031.5, Buisnes5 and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM o 9 O.-:10 ❑ I,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure °,° 21.5 0 is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S 'Permit $ ° m,° 2 1.5 5) ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE 0 3,2 O y 8 7 licensed Contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCYt�2 I hereby affirm that there is a construction lending agency SIGNED THIS 0 AY OFI for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, Civ. C.). OWNERS AGENT ADDRESS W• 6 Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon thea ve-men 'o ed property for inspection purposes. Signature of Per Ittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE